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Psychiatry and Psychology Services

Description:

Psychiatry and Psychology are specialized fields for the diagnosis and treatment of various mental health disorders and/or diseases.

Indications and Limitations of Coverage and/or Medical Necessity:

Information in this part of the policy has been divided into six (6) sections. These sections address each individual CPT/HCPCS procedure code.

General Clinical Psychiatric Diagnostic or Evaluative Interview Procedures
Special Clinical Psychiatric Diagnostic or Evaluative Procedures
Psychiatric Therapeutic Services
Psychiatric Somatotherapy
Other Psychiatric Disorders
Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing)
Section I:

General Clinical Psychiatric Diagnostic or Evaluative Interview Procedures

Description:

Procedure 90801 is described as the elicitation of a complete medical (including past, family, social) and psychiatric history, establishment of tentative diagnosis, and an evaluation of the patient's ability and willingness to work to solve the patient's mental problem. It includes a complete mental status exam. Information may be obtained from the patient, other physicians and/or family.

There may be overlapping of the medical and psychiatric history depending on the problem. An evaluation and management (E&M) service may be substituted for the initial interview procedure, including consultation codes (CPT 99241-99263), provided required elements of the E& M service billed are fulfilled.

Consultation services require, in addition to the interview and examination, the provision of a written opinion or advice. They do not include psychiatric treatment.

Documentation:

The medical record must reflect the elements outlined in the above description.

Comments:

This service may be covered once, at the onset of an illness or suspected illness. It may be utilized again for the same patient if a new episode of illness occurs after a hiatus, or on admission, or readmission, to inpatient status due to complications of the underlying condition.

Section II:
Special Clinical Psychiatric Diagnostic or Evaluative Procedures
Description:

Procedure 90802 is described as being used principally by child psychiatrists, psychologists and clinical social workers when they initially evaluate children who do not have the ability to interact with ordinary verbal communication. This code may also be applied to the initial evaluation of adult patients with organic mental deficits, or who are catatonic or mute.

The Interactive Medical Psychiatric Diagnostic Interview Examination (90802) includes the same components as the Psychiatric Diagnosis Interview Examination, which includes history, mental status, disposition, and other components as indicated.

However, in the interactive examination, the physician uses inanimate objects, such as toys and dolls for a child, physical aids and non-verbal communications to overcome barriers to therapeutic interaction, or an interpreter for a deaf person or one who does not speak English.

Documentation:

The medical record must indicate that the person being evaluated does not have the ability to interact through normal verbal communicative channels. If the patient is incapable of communication by any means this code may not be billed.

Comments:

Procedure code 90802 is covered for the interactive evaluations of children who are 16 years of age or younger, and of adults, who have one of the following conditions, as classified in the ICD-9-CM:

295.20-295.25
Schizophrenic disorders: catatonic type

299.00
Psychoses with origin specific to childhood: infantile autism, current or active state

299.80
Psychoses with origin specific to childhood: other specified early childhood psychoses current or active state


Other catatonic states may be covered if the documentation is submitted with the claim. Coverage also includes interactive examinations of patients with primary psychiatric diagnosis (e.g., Axis I DSM IV diagnoses), excluding the dementias (ICD-9-CM codes 290.0-290.9) and sleep disorders (ICD-9-CM 307.40-307.49), and one of the following conditions, as classified in the ICD-9-CM:



315.31
Developmental language disorder

315.39
Developmental speech or language disorder, other

389.00-389.08
Conductive hearing loss

389.10-389.18
Sensorineural hearing loss

389.2
Mixed conductive and sensorineural hearing loss

389.7
Deaf mutism, not elsewhere classified

389.8
Other specified forms of hearing loss

784.3
Aphasia

784.41
Aphonia

784.5
Other speech disturbance (dysarthria, dysphasia, slurred speech)




For the latter group of diagnoses, both the primary and secondary diagnoses must be submitted with the claim.

Description:

Procedure code 90885 is used when a physician is asked to do a review of records for psychiatric evaluation without direct patient contact. This may be accomplished at the request of an agency or peer review organization. It may also be employed as part of an overall evaluation or a patient's psychiatric illness or suspected psychiatric illness, to aid in the diagnosis and/or treatment plan.

Note: Effective January 1, 1996, Procedure code 90885 is considered to be bundled and not separately payable. Please refer to the Correct Coding Initiative information.

Section III:

Psychiatric Therapeutic Procedures

Description:

Procedure code 90865 is used for the administration of sedative or tranquilizer drugs, usually intravenously, to relax the patient and remove inhibitions for discussion of subjects difficult for the patient to discuss freely in the fully conscious state.

Documentation:



The medical record should document the medical necessity of this procedure, (i.e., the patient had difficulty verbalizing psychiatric problems without the aid of the drug). The record should also document the specific pharmacological agent, dosage administered, and whether the technique was effective or non-effective.

Comments: Use of code 90865 is restricted to physicians (M.D. or D.O. only).

Description:

Procedures 90804 through 90829 (Psychotherapy) are defined as "the treatment of mental illness and behavior disturbances in which the physician establishes a professional contract with the patient and through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior and encourage personality growth and development".

Documentation:

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive interactions, and interpretation of unconscious motivation, that were applied to produce therapeutic change.

Comments:

While a variety of psychotherapeutic techniques are recognized for coverage under these codes, a person authorized by the state to perform psychotherapy services must perform the services. Medicare coverage of procedure codes 90804-90829 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction, therefore, procedure codes 90804-90829 should not be used to bill for ADL training and/or social interaction skills.

Note: Procedure codes 90805, 90807, 90809, 90811, 90813, 90815, and 90817. 90819, 90822 and 90824, 90827 and 90829 include medical evaluation and management (E/M) service, which includes continuing medical diagnostic evaluations as well as pharmacologic management.

Therefore, pharmalogic management (90862) and E/M service codes may not be billed separately on the same day as a psychotherapy service by the same physician.

Guidelines for Procedure Codes 90804-90829

1. CPT codes 90841-90844 have a status "G" fee schedule. Therefore these codes are not valid for Medicare Part B reimbursement.

2. Individual psychotherapy codes should be used only when the focus of treatment encounter involves psychotherapy. Psychotherapy codes should not be used, as generic psychiatric service codes when another code, such as E/M or pharmacologic management code, would be more appropriate.

3. Prolonged treatment (in excess of twenty sessions per episode of illness) may be subject to medical review. Documentation must be present in the medical record indicating the necessity for prolonged treatment.

4. Procedure code 90808, 90809, 90814, 90815, 90821, 90822, 90828 and 90829 (approximately 75-80 minutes) should not routinely be used. They are reserved for exceptional circumstances. The provider must document in the patient's medical record the medical necessity of these services and define the exceptional circumstances.

5. Carriers will not accept psychiatric therapy procedure codes 90804-90829 being billed on the same day of service as an evaluation and management (E/M) service, by the same physician or mental health professional group. The single exception is that a consultation may be billed at the initial visit and psychotherapy may be billed on the same date of service, if it is medically indicated.

6. Psychotherapy services are not covered when documentation indicates that Dementia (ICD-9-CM codes 290.0, 290.20-290.9, 331.0-331.2) has produced a severe enough cognitive defect to psychotherapy to be effective. Severe and profound mental retardation (ICD-9 code 318.1 and 318.2) are never covered for psychotherapy services. In such cases, rehabilitative, evaluation and management (E/M) codes or pharmacologic management codes should be reported.

7. For psychotherapy sessions lasting longer that 90 minutes, reimbursement will only be made if a report is submitted with the claim, documenting the face-to-face time spent with the patient and the medical necessity for the extended time.

Description:

Procedure code 90845 is the practice of psychoanalysis, which uses special techniques to gain insight into and treat a patient’s unconscious motivations and conflicts, and is a different therapeutic modality than psychotherapy.

Documentation:

The medical record must document the indications for psychoanalysis, description of the transference, and the psychoanalytic techniques used.

Comments:

The physician using this technique must be trained and credentialed in its use. It is not time related, but the code is billed once for each daily session regardless of the time involved. The Relative Value Units (RVUs) assigned to this code are based on a 45-60 minute session. Psychoanalysis is generally considered unsuitable for psychoses.



Coverage includes the following diagnosis codes:



296.20-296.25
Major depressive disorder, single episode

296.30-296.35
Major depressive disorder, recurrent episode

300.01
Panic disorder

300.02
Generalized anxiety disorder

300.11
Conversion disorder

300.12
Psychogenic amnesia

300.13
Psychogenic fugue

300.20-300.29
Phobic disorders

300.3
Obsessive-compulsive disorders

300.4
Neurotic depression

309.1
Prolonged depressive reaction

309.21
Separation anxiety disorder

309.22
Emancipation disorder of adolescence and early adult life

309.23
Specific academic or work inhibition




Description:

Procedure codes 90846, 90847 and 90849 are used to describe family participation in the treatment process of the patient. Code 90846 is used when the patient is not present. Code 90847 is used when the patient is present. Code 90849 is intended for group therapy sessions for multiple families when similar dynamics are occurring due to a commonality of problems in the family members under treatment.

Documentation:

The medical record must document the conditions described under Description and Comments paragraphs relative to codes 90846, 90847 and 90849.

Comments:

The Carrier's Manual, Coverage Issues 35-14, states that family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient's condition. Examples are as follows:

When there is a need to observe and correct, through psychotherapeutic techniques, the patient's interaction with family members (CPT 90847).
Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient (90846 or 90847).
Procedure codes 90846 and 90847 represent psychotherapy services for treatment of mental disorders. They should not be used to code taking a family history or E/M counseling services.

Code 90849 has restrictive coverage and would generally be non-covered. Such group therapy is directed to the effects of the patients' condition on the family, and does not meet the carrier's standards of being part of the physician's personal services to the patient. If such is not the case, individual consideration may be given if documentation is submitted.

Description:

Psychotherapy administered in a group setting (90853) with a trained group leader in charge of several patients. Personal and group dynamics are discussed and explored in a therapeutic setting allowing emotional catharsis, instruction, insight, and support.

Documentation:

The record must indicate that the guidelines are Description and Comments were followed.

Comments:

Group therapy, since it involves psychotherapy, must be led by a person who is authorized by state statute to perform this service. This will usually mean a psychiatrist, psychologist, or clinical social worker and, in some states, certified nurse practitioners, clinical nurse specialists, or qualified mental health personnel.

For coverage, group therapy does not include socialization, music therapy, recreational activities, art classes, excursions, sensory stimulation or eating together, cognitive stimulation, motion therapy, etc.

Description:

90810- 90815, 90823- 90829 and 90857 are used when the patient, or patients in the group setting, does not have the ability to interact by ordinary verbal communication, and therefore non-verbal communication skills are employed, or an interpreter may be necessary. The guidelines in the Description, Documentation and Comments sections under CPT 90802 apply to codes 90810-90815, 90823-90829 and 90857.

Documentation:

Documentation in the medical record must include the need for interactive therapy. The guidelines in the Documentation Section under code 90802 apply to codes 90810-90815, 90823-90829 and 90857.

Comments:

Codes 90810-90815 and 90823-90829 should not be billed on the same dates of service as codes 90804-90809, or 90816-90822. Code 90857 should not be billed on the same date of service as 90853.

Section IV:

Psychiatric Somatotherapy

Description:

The physician who is prescribing pharmacologic therapy for a patient with an organic brain syndrome or whose diagnosis is in the ICD-9 range of 290.0-319, and is being managed primarily by psychotropic drugs intends code 90862 for use.

It may also be used for the patient whose psychotherapy is being managed by another health professional and the billing physician is managing the psychotropic medication. The service includes 1) prescribing medication, 2) monitoring the effect of medication and its side effects, and adjusting the dosage. Any psychotherapy provided is minimal and is usually supportive in nature.

Documentation:

The record must document that the guidelines under Description and Comments are followed.

Comments:

If the physician supplies other services in addition to pharmacologic management at the visit then an E/M code may be used. However the E/M service will include the pharmacologic management and therefore 90862 should not be billed in addition to the E/M service. Based on physician work relative value units, the physician work component of the code is similar to Code 99214 (equivalent to 25-30 minutes).

If the patient receives psychotherapy and pharmacologic management at the same visit the psychotherapy codes, which include evaluation, and management should be used. The pharmacologic management is included, as part of that E/M service by definition, and 90862 should not be billed in addition to the psychotherapy code.

90862 is not intended to be used for the actual administration, nor is it intended to be used for observation of the patient taking an oral medication. Administration and supply of oral medication is a non-covered service.

Codes 90862 and M0064 describe a physician service and cannot be billed by a non-physician or "incident to" a physician's service, with the exception that nurse practitioners whose scope of license in their states permit them to prescribe may use this code if they perform these services.

Code 90862 is not intended to refer to a brief evaluation of the patient's state or simple dosage adjustment of long-term medication. The code refers to the in-depth management of psychopharmacologic agents, which are potent medications with frequent serious side effects, and represents a very skilled aspect of patient care.

HCPCS' code M0064 should be used for the lesser level of drug monitoring such as simple dosage adjustment. M0064 is defined as a brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental, psychoneurotic and personality disorders. Based on the assignment of RVUs, the work involved in M0064 is similar to code 99212. Time spent is generally less than ten minutes.

Description:

Codes 90870 and 90871 are described as the application of electric current to the brain, through scalp electrodes to produce a single (90870) or multiple (90871) seizure.

Documentation and Comment:

When the psychiatrist administers the anesthesia for the electro convulsive seizure therapy, no separate payment may be made for that service.

Section V:

Other Psychiatric Therapy

Description:

Codes 90875 and 90876 are described as individual psycho physiological therapy incorporating biofeedback training by any method (face to face with patient).

Comments:

Coverage Issues Manual 35-27 restricts the use of biofeedback. Medicare does not cover biofeedback for the treatment of psychiatric disorders.

Description:

Code 90880 is described as medical hypnotherapy. Hypnosis is an artificially induced alteration of consciousness in which the patient is in a state of increased suggestibility.

Documentation:

Claims must be submitted with a covered diagnosis.

Comments:

Hypnosis may be used for diagnostic or therapeutic purposes. When used therapeutically to enhance psychotherapy or provided in conjunction with psychotherapy in the same session, only code 90880 or the psychotherapy code should be reported.

Carriers will cover hypnotherapy for the following diagnoses:



300.11
Conversion disorder

300.12
Psychogenic amnesia

300.13
Psychogenic fugue

300.14
Multiple personality

300.15
Dissociative disorder or reaction

300.20-300.29
Phobic disorders

307.80
Psychogenic pain, site unspecified

308.3
Other acute reactions to stress

308.4
Mixed disorders as reaction to stress

308.9
Unspecified acute reaction to stress

309.0
Brief depressive reaction

309.1
Prolonged depressive reaction

309.21-309.29
Adjustment reaction with predominant disturbance of other emotions

309.3
Adjustment reaction with predominant disturbance of conduct

309.4
Adjustment reaction with mixed disturbance of emotions and conduct

309.81
Prolonged posttraumatic stress disorder




Note: Code 90882, environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions is NONCOVERED.

Description:

Code 90887 is used when the treatment of the patient may require explanations to the family, employers, or other involved persons for their support in the therapy process. This may include reporting of examinations, procedures and other accumulated data.

Note: Effective January 1, 1996, code 90887 is considered to be a bundled service. Refer to the Correct Coding Initiative Information.

Description:

Code 90889 involves preparation of reports for insurance companies, agencies, courts, etc. Most carriers do not cover this service.

Section VI:

Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental Status, Speech Testing)

Description:

Code 96100 includes the administration, interpretation and scoring of tests mentioned in the CPT description and other medically accepted tests for evaluation of intellectual strengths, psychopathology, psychodynamics, mental health risks, insight, motivation and other factors influencing treatment and prognosis.



Documentation:

The medical records must indicate the presence of mental illness or signs of mental illness for which psychological testing is indicated as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved.

Comments:

These are not psychotherapeutic modalities, but are diagnosis aids. Use of such tests when mental illness is not suspected would be a screening procedure and not covered by the carriers. Each test performed must be medically necessary and therefore standardized batteries of tests are not acceptable. The Folstein Mini-Mental Exam (or similar test) is not separately reimbursable by Medicare and is included in the clinical interview or E/M service.

Changes in mental illness may require psychological testing to determine new diagnoses or the need for changes in therapeutic measure. Repeat testing not required for a diagnosis or continued treatment would be considered medically unnecessary. Nonspecific or disruptive behaviors, which do not indicate the presence of, or change in, a mental illness would not be an acceptable indication for testing. Psychological or psychiatric evaluations that can be accomplished through the clinical interview alone (e.g., response to medication) would not require psychological testing, and such testing might be considered as medically unnecessary. Adjustment reactions or dysphoria associated with moving to a nursing facility, do not constitute medical necessity for psychological testing.

Code 96100 should not be reported by the treating psychiatrist for reading the report of the results of psychological testing. Reading of the report is included in the office time, or floor time in the hospital, and would be bundled into the payment for other services.



Description:

Codes 96100, 96105, 96110, 96111, and 96115 are delineated in the CPT definition. Code 96117 describes testing which is intended, to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on the brain. Examples of problems, which might lead to neuropsychological testing, are:

Detection of neurologic diseases based on quantitative assessment of neurocognitive abilities (e.g., mild head injury, anoxic injuries, AIDS dementia).
Differential diagnosis between psychogenic and neurogenic syndromes
Delineation of the neurocognitive effects of CNS disorders
Neurocognitive monitoring of recovery or progression of CNS disorders; and,
Assessment of neurocognitive functions for the formulation of rehabilitation
and/or management strategies among individuals with neurologic disorders.


Documentation:

The medical record must document that the guidelines outlined in the Description and Comments were followed.

Comments (96117):

The content of Neuropsychological Testing procedures differs in a large part from that of Psychological Testing (96100). The Neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample ability domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.).

These procedures are objective and quantitative in nature and require the patient to directly demonstrate their level of competence in a particular cognitive domain. Neuropsychological Testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT).

These procedures are intended for psychological testing and should be covered under 96110. Brief screening measures such as the Folstein Mini Mental Status Exam or use of other mental status exams in isolation should not be classified separately as Neuropsychological Testing (96117) since they are typically part of a more general clinical exam or interview.

Typically, the test battery will require from 5-7 hours to perform, including administration, scoring and interpretation. If the testing is done over several days, the testing time should be combined and reported all on the last date of service. If the testing time exceeds 11 hours, a report must be submitted indicating the medical necessity for this extended testing.



Indications:

Neuropsychological conditions which fall under the Descriptions and Comments sections preceding. ICD-9 codes, which are descriptive of those conditions, will be covered for code 96117.



CPT/HCPCS Codes:



90801
Psy dx interview

90802
Intac psy dx interview

90804
Psytx, office, 20-30 min

90805
Psytx, off, 20-30 min w/e&m

90806
Psytx, off, 45-50 min

90807
Psytx, off, 45-50 min w/e&m

90808
Psytx, office, 75-80 min

90809
Psytx, off, 75-80, w/e&m

90810
Intac psytx, off, 20-30 min

90811
Intac psytx, 20-30, w/e&m

90812
Intac psytx, off, 45-50 min

90813
Intac psytx, 45-50 min w/e&m

90814
Intac psytx, off, 75-80 min

90815
Intac psytx, 75-80 w/e&m

90816
Psytx, hosp, 20-30 min

90817
Psytx, hosp, 20-30 min w/e&m

90818
Psytx, hosp, 45-50 min

90819
Psytx, hosp, 45-50 min w/e&m

90821
Psytx, hosp, 75-80 min

90822
Psytx, hosp, 75-80 min w/e&m

90823
Intac psytx, hosp, 20-30 min

90824
Intac psytx, hsp 20-30 w/e&m

90826
Intac psytx, hosp, 45-50 min

90827
Intac psytx, hsp 45-50 w/e&m

90828
Intac psytx, hosp, 75-80 min

90829
Intac psytx, hsp 75-80 w/e&m

90845
Psychoanalysis

90846
Family psytx w/o patient

90847
Family psytx w/patient

90849
Multiple family group psytx

90853
Group psychotherapy

90857
Intac group psytx

90862
Medication management

90865
Narcosynthesis

90870
Electroconvulsive therapy

90871
Electroconvulsive therapy

90875
Psychophysiological therapy

90876
Psychophysiological therapy

90880
Hypnotherapy

90882
Environmental manipulation

90885
Psy evaluation of records

90887
Consultation with family

90889
Preparation of report

90899
Psychiatric service/therapy

96100
Psychological testing

96105
Assessment of aphasia

96110
Developmental test, lim

96111
Developmental test, extend

96115
Neurobehavior status exam

96117
Neuropsych test battery

M0064
Visit for drug monitoring




The following list of covered ICD-9 and DSM IV diagnosis codes must be linked to the appropriate procedure before consideration for Medicare payment may be made. Refer to individual CPT code (S) coverage found in the Coverage and Limitations section of this policy.



290.11-290.13
Presenile dementia, with delirium, with delusional features, and with depressive features

290.20-290.21
Senile dementia with delusional or depressive features

290.3
Senile dementia with delirium

290.41-290.43
Arteriosclerotic dementia, with delirium, with delusional features, and with depressive features

291.0
Alcohol withdrawal delirum

291.1
Alcohol amnestic syndrome

291.3
Alcohol withdrawal hallucinosis

291.5
Alcoholic jealousy

291.81-291.89
Other specified alcoholic psychosis

291.9
Unspecified alcoholic psychosis

292.0-292.9
Drug psychoses

293.0
Transient organic psychotic conditions: acute delirium

293.81-293.89
Other specified transient organic mental disorders

293.9
Unspecified transient organic mental disorder

294.0-294.9
Other organic psychotic conditions (chronic)

295.10-295.15
Schizophrenic disorders: disorganized type

295.20-295.25
Schizophrenic disorders: catatonic type

295.30-295.35
Schizophrenic disorders: paranoid type

295.40-295.45
Schizophrenic disorders: acute schizophrenic episode

295.60-295.65
Schizophrenic disorders: residual schizophrenia

295.70-295.75
Schizophrenic disorders: schizo-affective type

295.90
Unspecified schizophrenia

296.00-296.96
Affective psychoses

297.1
Paranoia

297.2
Paraphrenia

297.3
Shared paranoid disorder

298.8
Other and unspecified reactive psychosis

298.9
Unspecified psychoses

299.00
Infantile autism, current or active state

299.10
Disintegrative psychosis, current or active state

299.80
Other specified early childhood psychoses, current or active state

300.01
Panic disorder

300.02
Generalized anxiety disorder

300.11-300.19
Hysteria (exclude 300.10)

300.21-300.29
Phobic disorders (exclude 300.20)

300.3
Obsessive-compulsive disorders

300.4
Neurotic depression

300.6
Depersonalization syndrome

300.7
Hypochondriasis

300.82
Undifferentiated somatoform disorder

301.13
Cyclothymic disorder

301.83
Borderline personality

302.70-302.79
Psychosexual dysfunction

303.90-303.93
Alcohol dependence syndrome

304.00-304.83
Drug dependence (exclude 304.90-304.93)

305.20-305.93
Nondependent abuse of drugs (exclude 305.1)

306.51
Psychogenic vaginismus

307.1
Anorexia nervosa

307.20-307.23
Tics

307.3
Stereotyped repetitive movements

307.42
Persistent disorder of initiating or maintaining sleep

307.44
Persistent disorder of initiating or maintaining wakefulness

307.46
Somnambulism or night terrors

307.50-307.59
Other and unspecified disorders of eating

307.80
Psychogenic pain, site unspecified

307.89
Other psychalgia

308.3
Other acute reactions to stress

309.0
Brief depressive reaction

309.1
Prolong depressive reaction

309.21
Separation anxiety disorder

309.23
Specific academic or work inhibition

309.24
Adjustment reaction with anxious mood

309.28
Adjustment reaction with mixed emotional features

309.3
Adjustment reaction with predominant disturbance of conduct

309.4
Adjustment reaction with mixed disturbance or emotions and conduct

309.81
Prolonged posttraumatic stress disorder

310.1
Organic personality syndrome

311
Depressive disorder, not elsewhere classified

312.81-312.89
Other specified disturbances of conduct, not elsewhere classified

313.23
Elective mutism

313.81
Oppositional disorder

313.82
Identity disorder

314.00-314.9
Hyperkinetic syndrome of childhood

315.00-315.9
Specific delays in development

317-318.2
Mental retardation (exclude 319)

332.1
Secondary Parkinsonism

333.7
Symptomatic torsion dystonia

333.82
Orofacial dyskinesia

333.90
Unspecified extrapyramidal disease and abnormal movement disorder

333.92
Neuroleptic malignant syndrome

333.99
Other extrapyramidal diseases and abnormal movements

347
Cataplexy and narcolepsy

389.00-389.08
Conductive hearing loss

389.10-389.18
Sensorineural hearing loss

389.2
Mixed conductive and sensorineural hearing loss

389.7
Deaf mutism, not elsewhere classifiable

780.09
Alteration of consciousness, other

780.52
Other insomnia

784.3
Aphasia

784.41
Aphonia

784.5
Other speech disturbance

995.2
Unspecified adverse effect of drug, medicinal and biological substance

995.50-995.59
Child maltreatment syndrome

995.80
Adult maltreatment, unspecified

995.81
Adult physical abuse

995.82
Adult emotional/psychological abuse

995.83
Adult sexual abuse

995.84
Other adult abuse and neglect




Reasons for Denial:

Medically unnecessary services are not covered.
Medical record documentation does not verify that the services described under
CPT codes 90801-90889, 96100-96117, or 90804-90829 were provided or that the services did not fall within the guidelines of this policy.
Services were not provided by a qualified provider (as defined by the carriers).
Noncovered ICD-9 Code(s):
Any ICD-9-CMD diagnosis code not listed in this policy or any DSM IV mental health diagnosis code that is not cited in this policy.
Noncovered Diagnosis: N/A


Coding Guidelines:

Individual psychotherapy codes should be used only when the focus treatment involves individual psychotherapy. There should also be documentation of the patient's capacity to participate in and benefit from psychotherapy, if psychotherapy is the chosen treatment.

The estimated duration of treatment in terms of number of sessions should be specified. There should be documentation in the medical record that the treatment is expected to improve the health status or function of the patient.

These codes should not be used as generic psychiatric service codes when other codes such as an Evaluation and Management service or pharmacologic code would be more appropriate.

The medical record should document the target symptoms, the goals of therapy and methods of monitoring outcome. It should also document why the chosen therapy is the appropriate treatment modality either in lieu of or in addition to another form of psychiatric treatment.

When HCPCS codes (90804-90829) are performed by a physician, CPT code 90862 is not a separate or additional benefit, but is included in the psychotherapy codes.

It should be noted that only psychotherapy codes, psychological and neuropsychological testing codes have time applied to the service.



Documentation Requirements:

The treating provider must document the medical necessity of the chosen treatment/testing in the patient's medical record. See individual sections for more specific documentation information. Documentation must be submitted to the carriers upon request.